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June 2014

Studies: Diabetes Prevalence Is Up While Diabetes Complications Are Down

By Brian McCurdy, Senior Editor

Two recent studies offer bad news and good news about diabetes. One study tracks a continued rise in the incidence of diabetes and stability in the numbers of those with undiagnosed diabetes, and the other study notes a decrease in complications of the disease.

A recent study in the Annals of Internal Medicine notes that over the last two decades, the prevalence of total confirmed diabetes has increased while the prevalence of undiagnosed diabetes remained fairly stable, thus reducing the proportion of total undiagnosed diabetes cases to 11 percent (of those estimated to have diabetes) from 2005 to 2010. Researchers say this suggests improvements in screening and diagnosis. The study adds that among the increasing population of those with diagnosed diabetes, glycemic control has improved but remains a challenge, particularly among non-Hispanic African Americans and Mexican Americans.

Another study in the New England Journal of Medicine notes that preventive care for adults with diabetes has improved substantially from 1990 through 2010. Researchers measured declines in the rates of acute myocardial infarction, death from hyperglycemic crisis, stroke, lower extremity amputations and end-stage renal disease. Despite the decline in diabetes complications, the study notes that “a large burden of disease persists” due to the increased prevalence of the disease.

Eric Jaakola, DPM, FACFAS, attributes the rise of diabetes to an exponential increase in population coupled with the rate of obesity in the United States and the direct relationship between obesity and diabetes. Barry Rosenblum, DPM, concurs that the rising incidence of obesity is a factor.

As far as the decrease in diabetes complications goes, Dr. Jaakola says this may be because preventative medicine is on the rise and primary care physicians are instituting more protocols that address the complications of diabetes.

“Better control of diabetes and overall management of the disease has certainly helped decrease the rate of complications,” says Dr. Rosenblum, the Associate Chief of Podiatry at the Beth Israel Deaconess Medical Center in Boston and an Assistant Clinical Professor of Surgery at Harvard Medical School. “However, the total number of complications continues to increase due to the larger number of patients diagnosed with diabetes.”

What actions can physicians and patients take to both lower diabetes prevalence and continue to reduce the complications of diabetes? Both Dr. Jaakola and Dr. Rosenblum emphasize the importance of patient diet with Dr. Jaakola stressing the choices a patient makes and the education about food that a physician gives. He suggests that his patients eat food with one ingredient, such as chicken or broccoli, and stay away from foods with more than three ingredients. Patients should also see their doctors on a routine basis, not just when something is wrong, according to Dr. Jaakola, who is in private practice at the Diabetic Foot and Wound Center in Denver.

Dr. Rosenblum adds that early diagnosis and control of blood sugar levels, once a physician has diagnosed diabetes, is a proven intervention that helps in reducing the risk of complications.

Vibram Settles Lawsuit Over Minimalist Shoes

By Brian McCurdy, Senior Editor

Following a class action lawsuit that its FiveFingers minimalist running shoes do not perform as advertised, Vibram USA recently agreed to a $3.75 million settlement.

The 2012 lawsuit challenged Vibram’s statement that the shoes would “reduce foot injuries and strengthen foot muscles,” according to a United Press International (UPI) report. The company will distribute the settlement to people with “valid and completed” complaints about the shoes. Vibram also agreed to stop advertising that the shoes strengthen foot muscles and prevent injury unless it finds scientific evidence proving otherwise, notes UPI.

Jenny Sanders, DPM, notes that the FiveFingers craze has “all but died” in San Francisco, where she has a private practice.

“Patients have stopped asking about them and none of the runners I’ve treated in the past 10 months have come in with injuries secondary to running in them,” she notes.

Dr. Sanders had been seeing metatarsal fractures due to the FiveFingers shoes but they have disappeared along with “questions and hysteria” over the minimalist and zero drop shoes.

Dr. Sanders cites the Hoka One One (Hoka One One Inc.) as the newest “fad” in running shoes, the polar opposite of FiveFingers. Although not necessarily a fan, she says the shoe is less prone than FiveFingers to causing injury. The shoe has a thick engineered midsole that has up to 2.5 times the volume of standard running shoes. The shoe also has a mild rocker sole that helps with propulsion, according to Dr. Sanders, an Adjunct Clinical Professor in the Department of Applied Biomechanics at the California College of Podiatric Medicine at Samuel Merritt University.

“Runners who continually seek out the latest fads in shoe design are the most at risk for injury and it is our job as experts to guide them to the most appropriate fit and styles based on their particular alignment and form,” says Dr. Sanders.

Can Dry Needling Help Relieve Plantar Heel Pain?

By Brian McCurdy, Senior Editor

A randomized controlled trial in Physical Therapy suggests that dry needling may be another effective modality to treat plantar heel pain.

Study authors recruited 84 patients with plantar heel pain for at least one month who received either trigger point dry needling or a sham needling treatment. Researchers noted the primary outcome measures were first step pain as measured by the Visual Analogue Scale and foot pain as measured by the Foot Health Status Questionnaire. They concluded that dry needling led to statistically significant improvements in pain in comparison to the sham treatment but cautioned that physicians should weigh the effect against minor transitory adverse events.

Matthew Cotchett, BSc, BPod (Hons), the lead investigator on the trial, says one could consider dry needling for plantar heel pain straight away, providing there are no contraindications in the patient’s medical history such as peripheral vascular disease or needle phobia, or the presence of severe hyperalgesia or allodynia, which could interfere with the use of dry needling. He does note there is little evidence to inform physicians when exactly to use dry needling so practitioners might want to try standard therapies first, like education, stretching, taping, and prefabricated foot orthoses. Cotchett and his co-authors, Shannon Munteanu, PhD, and Karl Landorf, PhD, FFPM, RCPS(Glasg), emphasize that practitioners need to have appropriate training to use this therapy to ensure they implement it in a safe and efficacious manner.

The authors note that in the trial, dry needling had a significant beneficial effect over a six- to 12-week period in comparison to a sham intervention but the benefit was slightly smaller than what patients consider clinically important. They compare the size of the effect to other commonly used interventions for plantar heel pain such as taping and foot orthoses.

“So combining dry needling with other evidence-based interventions is probably wise to maximize effectiveness,” says Dr. Landorf, a Senior Lecturer and Research Coordinator in the Department of Podiatry at La Trobe University in Victoria, Australia.

Study Compares First MPJ Arthrodesis In Patients With OA And RA

By Brian McCurdy, Senior Editor

First metatarsophalangeal joint (MPJ) arthrodesis can be beneficial for patients with osteoarthritis and rheumatoid arthritis. However, a recent study in the Journal of Foot and Ankle Surgery investigates whether each patient population heals differently.

The study authors analyzed 155 first MPJ fusions, 116 for patients with osteoarthritis pain and 39 for patients with rheumatoid arthritis. Patients with rheumatoid arthritis experienced a statistically shorter time to fusion while the incidence of fusion was 94 percent for patients with rheumatoid arthritis and 89 percent for those with osteoarthritis, according to the study.

Lead author Christopher Hyer, DPM, FACFAS, is not sure why rheumatoid arthritis patients achieve fusion quicker than osteoarthritis patients. In his practice, he saw results similar to those of the study for several years. In theory, the disease process with osteoarthritis, which has sclerotic, hyperdense bone, is more difficult biologically to heal, according to Dr. Hyer, the Fellowship Director and an attending physician at the Orthopedic Foot and Ankle Center in Westerville, Ohio.

Are there specific challenges for surgeons when performing first MPJ arthrodesis in arthritic patients? For rheumatoid arthritis patients, Dr. Hyer says one should confirm that the patients are off any disease modifying anti-rheumatic drugs (DMARDs) or prednisone if at all possible as both inhibit bone healing. For osteoarthritis patients, he suggests being hypervigilant in joint prep with thorough removal of dense subchondral bone and exposure of raw cancellous bone on both sides of the joint.